胸椎后纵韧带骨化症的临床分型及其意义

Classification of ossification of posterior longitudinal ligament in thoracic spine and its clinical meaning

中文关键词:  胸椎  后纵韧带骨化  胸椎管狭窄症  分型  手术策略

英文关键词:Thoracic  Ossification of posterior longitudinal ligament  Thoracic spinal stenosis  Classification  Strategy

中文摘要:

  【摘要】 目的：探讨基于CT、MRI影像学特征及病理改变部位、范围所制定的胸椎后纵韧带骨化（TOPLL）新的综合分型及其对治疗的指导价值。方法：纳入2007年5月～2013年6月入院诊治的胸椎后纵韧带骨化症患者49例，其中男8例，女41例，平均年龄51.8±8.7岁（36～71岁），平均病程15.2±21.9个月（1～120个月）。根据术前CT及MRI矢状位和轴位影像将TOPLL分为四型：Ⅰ型为上胸椎（T1～T4）局灶压迫型（1～2节段）；Ⅱ型为中下胸椎（T5～T12）局灶压迫（1～2节段），ⅡA型为不合并同节段黄韧带骨化（OLF）者，ⅡB型为合并OLF者；Ⅲ型为连续腹侧压迫（≥3个节段）；Ⅳ型为跳跃型TOPLL，ⅣA型为间隔≥3个节段者，ⅣB型为间隔＜3个节段者。将此分型应用于临床实践，记录患者的分型、手术相关数据、手术前后JOA评分及改善率，记录Frankel分级变化情况。结果：本组Ⅰ型6例，手术方案为经后路的环形减压（360°涵洞塌陷法）；ⅡA型2例，采用侧前方经胸/腹膜外入路减压，ⅡB型3例，采用经后路的环形减压；Ⅲ型30例，13例后纵韧带为平坦型，行单纯后壁切除术，余17例行广泛后壁切除联合局部环形减压；ⅣA型7例，采用经后路的环形减压术，ⅣB型1例，采用单纯后壁切除术。1例术后26个月死于脑干出血，余48例获得大于12个月随访，随访时间12～85个月，平均47±24个月。48例术前JOA评分4.6±1.8分（0～9分），术后JOA评分为8.8±2.1分（4～11分），平均改善率为（69±28）%（14%～100%）。依据Hirabayashi法对改善率进行分级，优23例、良9例、中16例。术前1例Frankel A级患者末次随访时改善为B级，22例Frankel B级患者中17例改善为C级，26例Frankel C级中2例改善为D级，余无变化。术后共11（22%）例发生脑脊液漏，其中单纯后壁切除1例，环形减压10例；均等引流液清亮后拔管，深缝伤口后沙袋加压包扎，俯卧位卧床2d，末次随访仅1例（T8～T12后壁切除、T8/9环形减压者）MRI提示T8/9水平筋膜外脑脊液囊肿存在（无症状），余10例MRI提示脑脊液已吸收。49例中无脊髓损伤及感染发生。结论：根据CT、MRI的影像形态学特征及病变所处位置、范围制定的胸椎OPLL临床实用分型方法，初步临床应用显示其对制定合理、安全的手术方案具有良好的指导作用。

英文摘要:

  【Abstract】 Objectives: To investigate a new compositive classification of thoracic posterior longitudinal ligament(TOPLL) based on the imaging features of CT, MRI and the position and range of pathological changes and its role in clinical practice. Methods: 49 patients, including 8 males and 41 females, diagnosed as TOPLL from May 2007 to June 2013 were collected in this series. The mean age was 51.8±8.7 years(36-71 years), and the average duration of disease was 15.2±21.9 months(1-120 months). According to pre-operative information on both sagittal and axial planes of CT and MRI, 4 types of TOPLL were classified in practice: Ⅰ, regional compression(1-2 segments) in proximal thoracic spine(T1-T4); Ⅱ, regional compression(1-2 segments) in middle and distal thoracic(T5-T12); ⅡA, without ossification of ligamentum flavum(OLF) at the same segment; ⅡB, with OLF at the same segment; Ⅲ, continuous ventral compressions(≥3 segments); Ⅳ, discontinuous type of TOPLL; ⅣA, discontinuous type of TOPLL(interval≥3 segments); ⅣB, discontinuous type of TOPLL(interval<3 segments). This classification was applied into clinical practice, the types of TOPLL, operative data, JOA scores at pre- and post-operation and recovery rates and Frankel classification were recorded. Results: A total of 49 patients was recruited in this study, 6 cases were classified as type Ⅰ, and the treatment strategy was 360° circumferential decompression(PCD), named "cave in" technique; 2 as ⅡA, and the treatment strategy was anterior decompression(AD); 3 as ⅡB, the treatment strategy was circumferential decompression(PD); 30 as Ⅲ, among them, 13 received PD and 17 received PCD; 8 as Ⅳ, among them, 7 ⅣA received PCD and 1 ⅣB received PD. One patient died from brainstem hemorrhage 26 months after surgery. The remaining 48 cases were followed up for 12-85 months with an average of 47±24 months. Pre-operative JOA scores of these 48 patients were 4.6±1.8(0-9), while 8.8±2.1(4-11) at final follow-up, with an average recovery rate of (69±28)%(14%-100%). According to the Hirabayashi grading for recovery rate, 23 patients were ranked as excellent, 9 as good, 16 as middle, none as unchange or worse. 1 patient with Frankel A pre-operatively improved to B at final follow-up. Among 22 cases with Frankel B, 17 improved to C, and 2 Frankel C improved to D at final follow-up. 11 cases(22%) were complicated with cerebrospinal fluid leakage, including 1 case of PD and 10 cases of PCD. The interventions included removal of drainage, stressful dressing and delayed off bed 2 days later. At final follow-up, only 1 case(T8-T12 PD combined with T8/9 PCD) was still found presence of cerebrospinal fluid at T8/9 on MRI, and in other 10 cases, the CSF completely disappeared. None developed injury of spinal cord or infection. Conculsions: This article proposes a novel classification of TOPLL, which takes the sites, distribution and sources of compression into account, and also proposes surgical strategies respectively. Primary application of this classification in clinical practice suggests its value.